Cannabis and harm reduction

Facilitators of and obstacles to practitioners' adoption of harm reduction in cannabis use: a scoping review

BACKGROUND

Cannabis use can generate potential avoidable harms, hence the need for effective preventive measures and treatment. Studies show the efficacy of harm reduction (HR) in minimizing undesirable consequences associated with this use. Despite its proven efficacy, HR in cannabis use remains poorly applied by many health and social services (HSS) practitioners, especially with young people. However, knowledge regarding the underlying reasons for this is limited. To fill this gap, we aimed to identify facilitators of and obstacles to HSS practitioners' adoption of HR in cannabis use across OECD countries.

METHODS

We conducted a scoping review, guided by Arksey and O'Malley's model. The search strategy, executed on health databases and in the grey literature, captured 1804 studies, of which 35 were retained. Data from these studies were extracted in summary sheets for qualitative and numerical analysis.

RESULTS

Facilitators and obstacles were grouped into four themes: stakeholders' characteristics (e.g., education, practice experience); clients' characteristics (e.g., personal, medical); factors related to HR (e.g., perceived efficacy, misconceptions); factors related to the workplace (e.g., type of workplace). Data were also extracted to describe the populations recruited in the selected studies: type of population, clientele, workplace.

CONCLUSION

Several factors might facilitate or hinder HSS practitioners' adoption of HR in cannabis use. Taking these into consideration when translating knowledge about HR can improve its acceptability and applicability. Future research and action should focus on this when addressing practitioners' adoption of HR.

Harm reduction isn't enough: Introducing the concept of Mindful Consumption and Benefit Maximization (MCBM)

The concept of harm reduction was a radical departure from a century of stigmatizing demand reduction initiatives targeted at people who use drugs. In fact, since the early 1980's Harm Reduction has been used with great success to protect the lives and wellbeing of these individuals. When employed with people who use opioids, the relevancy and importance of harm reduction are easy to grasp because the potential dangers are both quite visible and profound. However, promoting harm reduction practices to people consuming cannabis is a more difficult challenge. Cannabis cannot cause death due to overconsumption, is not associated with the spread of communicable diseases, and is overall a relatively harmless drug both to the individual and society when compared with other legal substances such as tobacco and alcohol. Harm reduction campaigns targeted at cannabis consumers run the risk of sounding overly fearful and stigmatizing, ultimately being ignored like many of the old demand reduction initiatives. Cannabis does have potential harms, and teaching people to mitigate those harms is an important public health goal. This commentary argues that cannabis education targeted at young people should employ mindful consumption and benefit maximization (MCBM) language that promotes harm reduction practices but does not focus on harm as the primary issue related to cannabis use. We define what we mean by mindful consumption and benefit maximization, identify their convergence with harm reduction principles, and argue for their use to both promote knowledge and normalize cannabis consumption that incorporates harm reduction practices.

Facilitators of and barriers to healthcare providers' adoption of harm reduction in cannabis use: a scoping review protocol

INTRODUCTION

The high prevalence of cannabis use and the potential for negative effects indicate the need for effective prevention strategies and treatment of people who use cannabis. Studies show that harm reduction (HR) in cannabis use is effective in minimising the harmful consequences of the substance. However, health professionals often misunderstand it and resist its adoption due to various obstacles. To our knowledge, there has been no review of the scientific literature on the factors that facilitate or hinder practitioners' adoption of HR in cannabis use. To fill this gap, we aim to identify, through a scoping review, facilitators and barriers to healthcare providers' adoption of HR in cannabis use in Organisation for Economic Cooperation and Development (OECD) countries.

METHODS AND ANALYSIS

Our methodology will be guided by the six-step model initially proposed by Arksey and O'Malley (2005). The search strategy will be executed on different databases (Medline, PsycINFO, CINAHL, Web of Science, Embase, Sociological Abstracts, Érudit, BASE, Google Web and Google Scholar) and will cover articles published between 1990 and October 2022. Empirical studies published in French or English in an OECD country and identifying factors that facilitate or hinder healthcare providers' adoption of HR in cannabis use, will be included. Reference lists of the selected articles as well as relevant systematic reviews will be scanned to identify any missed publications by the electronic searches.

ETHICS AND DISSEMINATION

Ethics approval is not required. The results will be disseminated through various activities (eg, publication in peer-reviewed journals, conferences, webinars and knowledge translation activities). The results will also allow us to conduct a future study aiming to develop and implement a knowledge translation process among healthcare practitioners working with youth in Quebec in order to enhance their adoption of HR in cannabis use.

Cannabis: An ancient friend or foe? What works and doesn't work

Cannabis has been cultivated by mankind for a multitude of uses over a period of thousands of years. This review explores how our relationship with the cannabis plant has evolved over this period of time, including the use of cannabis for recreational purposes and for its medicinal properties. The endocannabinoid system plays a complex role in the development of the fetal, infant and adolescent brain. Use of exogenous cannabinoids has the potential to result in supra-physiological stimulation and impact on normal central nervous system development. Cannabis is the most frequently used recreational drug in western societies and its use is common amongst pregnant women. This review summaries much of the evidence about what is known of the long term effects of in utero cannabis exposure. Further, the potential impact of use of medicinal cannabis products during pregnancy is considered and the implications to health professionals caring for pregnant women and their babies are explored.

The Qualitative Interview Study of Persistent and Nonpersistent Substance Use in the MTA: Sample Characteristics, Frequent Use, and Reasons for Use

OBJECTIVE

To evaluate participants' perceptions about frequent use and reasons for substance use (SU) in the qualitative interview study, an add-on to the multimodal treatment study of ADHD (MTA).

METHOD

Using the longitudinal MTA database, 39 ADHD cases and 19 peers with Persistent SU, and 86 ADHD cases and 39 peers without Persistent SU were identified and recruited. In adulthood, an open-ended interview was administered, and SU excerpts were indexed and classified to create subtopics (frequent use and reasons for use of alcohol, marijuana, and other drugs).

RESULTS

For marijuana, the Persistent compared with Nonpersistent SU group had a significantly higher percentage of participants describing frequent use and giving reasons for use, and the ADHD group compared with the group of peers had a significantly higher percentage giving "stability" as a reason for use.

CONCLUSION

Motivations for persistent marijuana use may differ for adults with and without a history of ADHD.

Harm reduction for cannabis: Factor analysis of a protective behavioral strategies survey

OBJECTIVE

To examine the psychometric properties of a measure of cannabis-specific Protective Behavioral Strategies (PBS), which assesses ways in which students may reduce cannabis-related risk.

PARTICIPANTS

Respondents to the American College Health Association - National College Health Assessment II (N = 580) during Spring 2015.

METHODS

Exploratory Factor Analysis (EFA) and Exploratory Structural Equation Modeling (ESEM) were used to identify and replicate the factor structure of the measure.

RESULTS

Results support a four-factor model (Respiratory Health, Frequency/Quantity, Socializing, and General Health) with close approximate fit (Χ² (310) = 565.96, p < .001, RMSEA = .038 (.033, .043; 90% CI), CFI = .961, TLI = .929, SRMR = .033). Support for the convergent validity and construct validity of the measure was also found.

CONCLUSIONS

This is the initial step in the development of a standard, psychometrically validated measure of cannabis PBS that has the potential to inform future research and interventions.

Lower-Risk Cannabis Use Guidelines: A Comprehensive Update of Evidence and Recommendations

BACKGROUND

Cannabis use is common in North America, especially among young people, and is associated with a risk of various acute and chronic adverse health outcomes. Cannabis control regimes are evolving, for example toward a national legalization policy in Canada, with the aim to improve public health, and thus require evidence-based interventions. As cannabis-related health outcomes may be influenced by behaviors that are modifiable by the user, evidence-based Lower-Risk Cannabis Use Guidelines (LRCUG)-akin to similar guidelines in other health fields-offer a valuable, targeted prevention tool to improve public health outcomes.

OBJECTIVES

To systematically review, update, and quality-grade evidence on behavioral factors determining adverse health outcomes from cannabis that may be modifiable by the user, and translate this evidence into revised LRCUG as a public health intervention tool based on an expert consensus process.

SEARCH METHODS

We used pertinent medical search terms and structured search strategies, to search MEDLINE, EMBASE, PsycINFO, Cochrane Library databases, and reference lists primarily for systematic reviews and meta-analyses, and additional evidence on modifiable risk factors for adverse health outcomes from cannabis use.

SELECTION CRITERIA

We included studies if they focused on potentially modifiable behavior-based factors for risks or harms for health from cannabis use, and excluded studies if cannabis use was assessed for therapeutic purposes.

DATA COLLECTION AND ANALYSIS

We screened the titles and abstracts of all studies identified by the search strategy and assessed the full texts of all potentially eligible studies for inclusion; 2 of the authors independently extracted the data of all studies included in this review. We created Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow-charts for each of the topical searches. Subsequently, we summarized the evidence by behavioral factor topic, quality-graded it by following standard (Grading of Recommendations Assessment, Development, and Evaluation; GRADE) criteria, and translated it into the LRCUG recommendations by the author expert collective on the basis of an iterative consensus process.

MAIN RESULTS

For most recommendations, there was at least "substantial" (i.e., good-quality) evidence. We developed 10 major recommendations for lower-risk use: (1) the most effective way to avoid cannabis use-related health risks is abstinence, (2) avoid early age initiation of cannabis use (i.e., definitively before the age of 16 years), (3) choose low-potency tetrahydrocannabinol (THC) or balanced THC-to-cannabidiol (CBD)-ratio cannabis products, (4) abstain from using synthetic cannabinoids, (5) avoid combusted cannabis inhalation and give preference to nonsmoking use methods, (6) avoid deep or other risky inhalation practices, (7) avoid high-frequency (e.g., daily or near-daily) cannabis use, (8) abstain from cannabis-impaired driving, (9) populations at higher risk for cannabis use-related health problems should avoid use altogether, and (10) avoid combining previously mentioned risk behaviors (e.g., early initiation and high-frequency use).

AUTHORS' CONCLUSIONS

Evidence indicates that a substantial extent of the risk of adverse health outcomes from cannabis use may be reduced by informed behavioral choices among users. The evidence-based LRCUG serve as a population-level education and intervention tool to inform such user choices toward improved public health outcomes. However, the LRCUG ought to be systematically communicated and supported by key regulation measures (e.g., cannabis product labeling, content regulation) to be effective. All of these measures are concretely possible under emerging legalization regimes, and should be actively implemented by regulatory authorities. The population-level impact of the LRCUG toward reducing cannabis use-related health risks should be evaluated. Public health implications. Cannabis control regimes are evolving, including legalization in North America, with uncertain impacts on public health. Evidence-based LRCUG offer a potentially valuable population-level tool to reduce the risk of adverse health outcomes from cannabis use among (especially young) users in legalization contexts, and hence to contribute to improved public health outcomes.

Feasibility and impact of brief interventions for frequent cannabis users in Canada

Cannabis use is prevalent among young people, and frequent users are at an elevated risk for health problems. Availability and effectiveness of conventional treatment are limited, and brief interventions (BIs) may present viable alternatives. One hundred thirty-four young high-frequency cannabis users from among university students were randomized to either an oral (C-O; n = 25) or a written experimental cannabis BI (C-W; n = 47) intervention group, or to either an oral (H-O; n = 25) or written health BI (H-W; n = 37) control group. Three-month follow-up assessments based on repeated measures analysis of variance techniques found a decrease in the mean number of cannabis use days in the total sample (p = 0.024), reduced deep inhalation/breathholding use in the C-O group (p = 0.003), reduced driving after cannabis use in the C-W group (p = 0.02), and a significant reduction in deep inhalation/breathholding in the C-O group (p = 0.011) compared with controls. Feasibility and short-term impact of the BIs were demonstrated, yet more research is needed.

Lower Risk Cannabis use Guidelines for Canada (LRCUG): a narrative review of evidence and recommendations

OBJECTIVES

More than one in ten adults--and about one in three young adults--report past year cannabis use in Canada. While cannabis use is associated with a variety of health risks, current policy prohibits all use, rather than adopting a public health approach focusing on interventions to address specific risks and harms as do policies for alcohol. The objective of this paper was to develop 'Lower Risk Cannabis Use Guidelines' (LRCUG) based on research evidence on the adverse health effects of cannabis and factors that appear to modify the risk of these harms.

METHODS

Relevant English-language peer-reviewed publications on health harms of cannabis use were reviewed and LRCUG were drafted by the authors on the basis of a consensus process.

SYNTHESIS

The review suggested that health harms related to cannabis use increase with intensity of use although the risk curve is not well characterized. These harms are associated with a number of potentially modifiable factors related to: frequency of use; early onset of use; driving after using cannabis; methods and practices of use and substance potency; and characteristics of specific populations. LRCUG recommending ways to reduce risks related to cannabis use on an individual and population level--analogous to 'Low Risk Drinking Guidelines' for alcohol--are presented.

CONCLUSIONS

Given the prevalence and age distribution of cannabis use in Canada, a public health approach to cannabis use is overdue. LRCUG constitute a potentially valuable tool in facilitating a reduction of health harms from cannabis use on a population level.

Adaptation of the patient feedback survey at a community treatment setting

The Patient Feedback Survey is a performance improvement measure designed to assess the quality of outpatient substance abuse treatment. We modified and administered this measure to 500 individuals at a multisite treatment provider. Although the feedback scores were high in general, analyses of variance showed score variability in relation to type and length of treatment. Moreover, respondents who reported any use of marijuana, cravings for substances, or mutual-support group attendance (ie, Alcoholics Anonymous or Narcotics Anonymous) had lower feedback scores than respondents without these experiences. We highlight the importance of investigating treatment evaluations in the context of other recovery experiences. 

Adding tobacco to cannabis--its frequency and likely implications

INTRODUCTION

Young cannabis users are at increased risk of later cigarette initiation and progression to nicotine addiction. The present study addresses the frequency at which mulling (adding tobacco to cannabis smoked as joints) is performed and in which way this practice varies according to cigarette smoking status.

METHODS

Data were issued from the Swiss 2007 European School Survey Project on Alcohol and other Drugs (ESPAD). A total of 881 past month cannabis users (mean age 15 years, boys 60.1%) were inquired on mulling using an anonymous self-administered questionnaire. Participants were further grouped according to their cigarette smoking status (daily, occasional, former, and never-smokers).

RESULTS

Four of every 5 cannabis users depicted mulling as frequently performed. The highest occurrence was found among daily cigarette smokers (DSC; 90.3%), while former cigarette smokers reported the lowest (58.9%). The multinomial logistic regression showed DSC more likely reporting mulling as frequent compared with never-smokers (risk ratio = 3.56 [95% CI 1.55-8.21]).

CONCLUSIONS

Mulling appears to be a very common process among young cannabis users, especially among concomitant cigarette smokers. Nevertheless, the majority of cigarette abstainers also reported frequently adding tobacco to the cannabis they smoke. Because it may represent a significant exposition to nicotine, mulling should be taken into account when assessing substance use among adolescents and in supporting their quitting attempts.

Cannabis use in Canada: the need for a 'public health' approach

Cannabis is the most commonly used illicit drug in Canada, used by 1 in 7 adults and 1 in 4 students. Other forms of drug use (e.g., alcohol or injection drug use) are increasingly approached within a public health policy framework that focuses on reducing harms rather than use per se. Cannabis, by contrast, remains formally controlled by a criminal justice approach that focuses on enforcing abstinence. Its use is associated with a variety of possible acute or chronic health problems that include cognitive and respiratory impairment, psychotic episodes, dependence and injury risk. The incidence of these outcomes, however, is predicted by early onset and a high frequency and length of use that only apply to a minority of users. In a public health framework, cannabis use - especially in young populations - should be systematically monitored and high-risk patterns of use screened for in appropriate settings, e.g., schools and GP offices. Evidence-based primary and secondary prevention, treatment and enforcement need to be targeted at these high-risk patterns of use. Given the large cannabis user population, especially among young people, and the failure of the criminalization approach to discourage use, a public health framework for cannabis use is urgently needed in Canada.

Typologies of cannabis users and associated characteristics relevant for public health: a latent class analysis of data from a nationally representative Canadian adult survey

Cannabis is the most prevalently used illicit drug in Canada. Current policy consists primarily of universal use prohibition rather than interventions targeting specific risks and harms relevant for public health. This study aimed to identify distinct groups of cannabis users based on defined use characteristics in the Canadian population, and examine the emerging groups' associations with differential risk and harm outcomes. One thousand three hundred and three current (i.e. use in the past three months) cannabis users, based on data from the representative cross-sectional 2004 Canadian Addiction Survey (N = 13,909), were statistically assessed by a 'latent class analysis' (LCA). Emerging classes were examined for differential associations with socio-demographic, health and behavioral indicators on the basis of chi-square and analysis of variance techniques. Four distinct classes based on use patterns were identified. The class featuring earliest onset and highest frequency of use [22% of cannabis user sample or 2.2% (95% confidence interval (CI) = 1.8-2.7%) of the Canadian adult population] was disproportionately linked to key harms, including other illicit drug use, health problems, cannabis use and driving, and cannabis use problems. A public health framework for cannabis use is needed in Canada, meaningfully targeting effective interventions towards the minority of users experiencing elevated levels of risks and harms.

Expected impacts of the Cannabis Infringement Notice scheme in Western Australia on regular users and their involvement in the cannabis market

The effect on the cannabis market is one area of interest in the evaluation of the new 'prohibition with civil penalties' scheme for minor cannabis offences in WA. One goal of the scheme is to reduce the proportion of cannabis consumed that is supplied by large-scale suppliers that may also supply other drugs. As part of the pre-change phase of the evaluation, 100 regular (at least weekly) cannabis users were given a qualitative and quantitative interview covering knowledge and attitudes towards cannabis law, personal cannabis use, market factors, experience with the justice system and impact of legislative change. Some 85% of those who commented identified the changes as having little impact on their cannabis use. Some 89% of the 70 who intended to cultivate cannabis once the CIN scheme was introduced suggested they would grow cannabis within the two non-hydroponic plant-limit eligible for an infringement notice under the new law. Only 15% believed an increase in self-supply would undermine the large scale suppliers of cannabis in the market and allow some cannabis users to distance themselves from its unsavoury aspects. Only 11% said they would enter, or re-enter, the cannabis market as sellers as a result of the scheme introduction. Most respondents who commented believed that the impact of the legislative changes on the cannabis market would be negligible. The extent to which this happens will be addressed in the post-change phase of this research. Part of the challenge in assessing the impact of the CIN scheme on the cannabis market is that it is distinctly heterogeneous.

Pot, politics and the press-reflections on cannabis law reform in Western Australia

Windows of opportunity for changing drug laws open infrequently and they often close without legislative change being affected. In this paper the author, who has been intimately involved in the process, describes how evidence-based recommendations to 'decriminalize' cannabis have recently been progressed through public debate and the political process to become law in Western Australia (WA). The Cannabis Control Bill 2003 passed the WA Parliament on 23 September. The Bill, the legislative backing behind the Cannabis Infringement Notice (CIN) Scheme, came into effect on 22 March 2004. This made WA the fourth Australian jurisdiction, after South Australia, the Australian Capital Territory and the Northern Territory, to adopt a prohibition with civil penalties scheme for minor cannabis offences. This paper describes some of the background to the scheme, the process by which it has become law, the main provisions of the scheme and its evaluation. It includes reflections on the role of politics and the press in the process. The process of implementation and evaluation are outlined by the author, foreshadowing an ongoing opportunity to understand the impact of the change in legislation.

Cannabis‐related problems and their management

Despite being the most common illicit drug in the Western world, treatment for cannabis use is not readily available. Primary health care and even specialist drug treatment services have often under‐recognised, and undertreated, cannabis‐related problems. Australian researcher Jan Copeland is one of the few people to test cannabis treatment models. Here she outlines the most effective models for treating cannabis and how they can be applied to other services.

Arrests and convictions for cannabis related offences in a New Zealand birth cohort

AIMS

To examine the associations between the use of cannabis and arrest/conviction for cannabis related offences.

METHODS

Data on cannabis use and arrests/convictions for cannabis related offences were gathered during the course of a 21-year longitudinal study of a birth cohort of Christchurch (New Zealand) born children (N=983). Information on cannabis use, arrests and convictions was gathered over the period from 16 to 21 years.

RESULTS

By the age of 21, over two thirds of the cohort had used cannabis on at least one occasion with 5% using cannabis on more than 400 occasions. Amongst cannabis users, 5.1% had been arrested for a cannabis related offence and 3.6% had been convicted of an offence. There was a strong association between the extent of cannabis use and risks of arrest/conviction: over a quarter of those using cannabis on more than 400 occasions had been arrested or convicted for a cannabis related offence compared with less than 1% of those using cannabis on fewer than ten occasions. Māori, those with a previous arrest record for non cannabis related offences and those reporting involvement in violent/property offending were more likely to be arrested or convicted than other cohort members having the same level of cannabis use; in addition, males were more likely to be convicted than females with the same level of cannabis use. Arrest/conviction for a cannabis related offence did not reduce the use of cannabis: of those arrested/convicted, 95% either increased their use or continued with the same level of cannabis use subsequent to their arrest.

CONCLUSIONS

The results of this study reinforce concerns about laws relating to the use and possession of cannabis. The findings show that the law was administered in an inefficient way, the application of the law was biased, and the law was ineffective in reducing cannabis use.

The THC content of cannabis in Australia: evidence and implications

OBJECTIVE

To examine evidence on three claims that: 1) the THC content of Australian cannabis plants has increased up to 30 times; 2) problems experienced by cannabis users have increased in Australia in recent years; and 3) an increase in THC content is the most likely explanation of any increase in cannabis-related problems.

METHODS

These claims were assessed by examining data: 1) on THC potency in Australia, the United States and New Zealand; 2) on cannabis-related problems; and 3) from the 1998 National Drug Strategy Household Survey on patterns of cannabis use.

RESULTS

1) Published data do not show a 30-fold increase in THC potency of cannabis but show a more modest increase in the US. 2) There is suggestive evidence of an increase in cannabis-related problems among people seeking treatment for alcohol and drug problems, juvenile offenders and young adults with psychosis. 3) There are two other more plausible explanations for these reportedly higher rates of cannabis-related problems among adolescents and young adults: (i) more potent forms of cannabis ('heads') are more widely used; and (ii) cannabis users are initiating cannabis at an earlier age, thereby increasing the prevalence of harmful patterns of use.

CONCLUSIONS

There has probably been a modest increase in the THC content of cannabis, but changing patterns of cannabis use have probably made a larger contribution to any increase in rates of cannabis-related problems among young Australian adults.

IMPLICATIONS

Better data on the THC content of cannabis, the extent of cannabis-related problems and the ability of users to titrate the dose of cannabis would contribute to more informed debate.